Nonspecialists Can Take on Psychotherapy Tasks Too

Trained nurses, midwives, and doulas can provide a brief form of psychotherapy for perinatal depression treatment via telemedicine as effectively as psychologists and psychiatrists, according to a new study.

After six to eight treatment sessions, patients reported significant improvements in their symptoms of depression and anxiety, regardless of the type of treatment provider.

Telemedicine and sharing mental health care responsibilities with nonspecialists are not meant to replace in-person therapy from trained specialists, the study authors noted. But they can offer options to patients facing untreated mental health conditions, particularly during the critical perinatal period.

“We know that psychotherapies — or talk therapies — are among the most effective interventions in mental health care, are vastly preferred by pregnant and postpartum populations over pharmacological treatments, and are recommended by most clinical guidelines to treat these common conditions of perinatal depression and anxiety,” said Daisy Singla, PhD, the lead author and a clinician scientist at the Lunenfeld-Tanenbaum Research Institute, which is part of Sinai Health in Toronto. Singla is also a senior scientist at the Centre for Addiction and Mental Health and an associate professor of psychiatry at the University of Toronto, both in Toronto.

“It is critical to increase access to psychotherapies for this population because prevalence is high and these conditions are treatable,” she said. “When left untreated, perinatal depression and anxiety have significant negative impacts on the patient, her children, and society at large. Older economic estimates suggest that untreated perinatal mood and anxiety disorders amount up to $14 billion USD annually.”

The study was published online on March 3 in Nature Medicine.

The Scaling Up Maternal Mental health care by Increasing access to Treatment (SUMMIT) Trial

Singla and colleagues aimed to address this treatment gap by comparing two patient-centered solutions — telemedicine and task sharing — to the gold standard of care with specialists and in-person sessions. SUMMIT is considered one of the largest psychotherapy trials in the world.

Conducted in five hospitals across Toronto, Chicago, and Chapel Hill, North Carolina, between January 2020 and October 2023, the trial included 1230 pregnant and postpartum participants, with nearly 50% identifying as racial and ethnic minorities. The participants were randomly assigned to four arms: 472 to nonspecialist telemedicine, 469 to specialist telemedicine, 145 to nonspecialist in-person, and 144 to specialist in-person. The outcomes were assessed at a 3-month follow-up between March 2020 and February 2024.

As part of the program, participants received between six and eight weekly sessions of behavioral activation therapy, which encourages participants to engage in meaningful activities that align with their personal values. Previous studies have demonstrated that this therapy alleviates symptoms of depression and anxiety.

At baseline, participants’ average age was 33 years, 99.6% identified as cisgender women, and 54% were nulliparous. About 86% reported a history of depression or anxiety, and 23% reported taking psychotropic medications at enrollment. Although baseline characteristics were balanced between the four trial arms, 61% of participants expressed an initial preference for specialist treatment, and 62% expressed a preference for telemedicine.

After treatment, depression scores decreased from an average of 16 to 9 on the Edinburgh Postnatal Depression Scale (EPDS), indicating that participants moved below the mild depression threshold of 10.

In addition, anxiety scores decreased from an average of 12 to 7 on the Generalized Anxiety Disorder 7 (GAD-7) scale, indicating that participants dropped below the clinical threshold of 8.

Overall, there were no statistically or clinically meaningful differences between the treatment providers (specialists vs nonspecialists) or modality (telemedicine vs in-person).

In particular, noninferiority was met for the primary outcomes comparing providers (EPDS: nonspecialist, 9.27 vs specialist, 8.91) and modality (EPDS: telemedicine, 9.15 vs in-person, 8.92) for both intention-to-treat and per-protocol analyses.

Noninferiority was also met for anxiety symptoms when comparing providers (GAD-7: nonspecialist, 6.44 vs specialist, 6.36) and modality (GAD-7: telemedicine, 6.43 vs in-person, 6.29) for intention-to-treat analyses.

Notably, the improvements occurred regardless of symptom severity before treatment, whether mild, moderate, or severe, Singla said. Also, there were no serious or adverse events related to the trial.

“Task sharing and telemedicine offer hope for new and expecting parents by treating depression and anxiety through straightforward, evidence-based solutions,” she said. “Leveraging these simple, pragmatic solutions has the potential to transform healthcare and improve access to essential mental health services.”

Implications for Patients

Approximately 1 in 5 pregnant and postpartum participants experience depression and anxiety, yet less than 10% receive proper treatment, the study authors wrote.

Untreated depression and anxiety can lead to maternal mortality, obstetric complications, and developmental problems in children, Singla said. Investing in perinatal mental health could lead to positive outcomes for parents, children, and communities at large, she added.

“From a clinical perspective, the SUMMIT trial provides robust support to healthcare providers to match patients’ preferences and use telemedicine in the management of some of the most common perinatal mental health conditions,” said Benicio Frey, MD, PhD, the Homewood Research Chair in Women’s Mental Health and Depression and professor of psychiatry and behavioral neurosciences at McMaster University in Hamilton, Ontario.

Frey, who was not involved with this study, is a member of the Canadian Network for Mood and Anxiety Treatments and co-authored the group’s recent 2024 clinical practice guideline for the management of perinatal mood, anxiety, and related disorders.

“SUMMIT also paves the way for policymakers and governmental agencies on cost-effective and scalable ways to improve accessibility to effective treatments to underserved populations,” he said.

The SUMMIT trial was funded by a Patient-Centered Outcomes Research Institute award. Singla and Frey reported no relevant financial disclosures.

Carolyn Crist is a health and medical journalist who reports on the latest studies for Medscape Medical News, MDedge, and WebMD.